Intracranial Hemorrhage on Intracranial Hemorrhage on CT CT

Tobias Potzger Tobias Potzger (Ludwig(Ludwig--MaximiliansMaximilians--University Munich)University Munich)

Gillian Lieberman, MDGillian Lieberman, MD

June 2008June 2008

AgendaAgenda

Review of Review of neuroanatomyneuroanatomy

CTCT-- appearance of intracranial appearance of intracranial hemorrhagehemorrhage

Patient presentationPatient presentation

Appearance of cerebral edema and Appearance of cerebral edema and herniationherniation

Review AnatomyReview Anatomy

Meninges of the brain(1)

Arterial SystemArterial System

(2)

(6)

Venous SystemVenous System

(6)

Venous SystemVenous System

Gray`s figure 570#, 578#

CerebrospinalCerebrospinal--Fluid SystemFluid System

Cerebrospinal-Fluid System (3)

CerebrospinalCerebrospinal--Fluid FlowFluid Flow

(7)(13)

Our Patient: History Our Patient: History

History:History:49 year old man49 year old manNo significant No significant PMHxPMHxInvolved in several low speed Involved in several low speed accidentsaccidentsSlurred speech/word substitutionsSlurred speech/word substitutionsdisorientationdisorientation

Our Patient examinationOur Patient examination

Outside Hospital ED 1Outside Hospital ED 1stst day:day:No feverNo feverNo headache, no neck stiffness, no No headache, no neck stiffness, no photophobia or visual changesphotophobia or visual changesWBC 7,9 WBC 7,9 CTCT

Our Patient: Head CTOur Patient: Head CT

(14)

No significant findings

Our Patient CourseOur Patient Course

No significant CTNo significant CT--head findingshead findings

Return to normal mental statusReturn to normal mental status

Patient was discharged from the EDPatient was discharged from the ED

Advantages Advantages Head Head CT CT

Detects acute bleedingDetects acute bleeding

FastFast

Simultaneous assessment of bone Simultaneous assessment of bone and brain tissue and brain tissue

Availability Availability

Appearance of Hemorrhage on Appearance of Hemorrhage on CTCT

<12h<12h isodenseisodense12h 12h -- 7d 7d hyperdensehyperdense7d 7d –– 1 month 1 month isodenseisodense> 1 month> 1 month isodenseisodense hypodensehypodense

Epidural Hemorrhage (EDH) on CTEpidural Hemorrhage (EDH) on CT

(BIDMC)

Companion Patient 1Companion Patient 1

Axial, CCT C-

Epidural Hemorrhage: FactsEpidural Hemorrhage: Facts11--4% of patients with intracranial trauma4% of patients with intracranial trauma8585--95% middle 95% middle meningealmeningeal artery or a artery or a duralduralvenous sinus venous sinus 95% unilateral and 95% unilateral and supratentorialsupratentorial66% of acute epidural hematomas are 66% of acute epidural hematomas are hyperdensehyperdense on CTon CT33% contain 33% contain hypodensehypodense areas secondary to areas secondary to active bleedingactive bleedingLucid intervalLucid intervalDoes not cross suture marginsDoes not cross suture marginsMidline shiftMidline shift

Subdural Hemorrhage (SDH) on CTSubdural Hemorrhage (SDH) on CT

(5)Axial CCT, C-

Companion Patient 2Companion Patient 2

Subdural Hemorrhage: FactsSubdural Hemorrhage: Facts

most common extramost common extra--axial collectionaxial collectionseen in 5% of head trauma patientsseen in 5% of head trauma patientsUsually due to traumatic bleeding Usually due to traumatic bleeding from the "bridging" subdural veinsfrom the "bridging" subdural veinstend to conform to the shape of the tend to conform to the shape of the brainbrainCrescent shapeCrescent shapeCan cross suturesCan cross suturesMidline shiftMidline shift

Subdural HemorrhageSubdural Hemorrhage

Crescent shape

Midline Shift

(5)

Companion Patient 2

Axial CCT, C-

Subarachnoid Hemorrhage (SAH) Subarachnoid Hemorrhage (SAH) on CTon CT

(7)

Companion Patient 3Companion Patient 3

Axial, CCT C-

Subarachnoid Hemorrhage: FactsSubarachnoid Hemorrhage: Facts

Most frequent causes:Most frequent causes:Head trauma Head trauma Intracranial aneurysms (80% of Intracranial aneurysms (80% of nontraumatic)nontraumatic)Most occur around the circle of Willis Most occur around the circle of Willis (berry aneurysm) at (berry aneurysm) at

Middle cerebral artery bifurcation Middle cerebral artery bifurcation Anterior communicating artery Anterior communicating artery Posterior communicating artery Posterior communicating artery

Berry AneurysmBerry Aneurysm

(10) (11)

Subarachnoid Hemorrhage: FactsSubarachnoid Hemorrhage: Facts

Less frequent causes:Less frequent causes:•• Arteriovenous malformation (AMV)Arteriovenous malformation (AMV)•• Extension from intracerebral Extension from intracerebral

hemorrhagehemorrhage•• Arteriovenous fistulae Arteriovenous fistulae •• Meningitis Meningitis •• NeoplasmNeoplasm

SAH Clinical FindingsSAH Clinical Findings

Headache (Headache (““worst headache of lifeworst headache of life””))NauseaNauseaVomitingVomitingDisorientation, confusionDisorientation, confusion

SAHSAH

Attenuation blood is noted in the:

- Suprasellar cistern

- Sylvian fissur

- Interpeduncular cistern

(7)Axial CCT, C-

Companion Patient 3

Our Patient followOur Patient follow--upup

10 h later/ 210 h later/ 2ndnd day:day:patient was found unresponsive and patient was found unresponsive and pulslesspulsless (max. 15min)(max. 15min)CPR, defibrillation x1CPR, defibrillation x1Transport to outside hospitalTransport to outside hospital-- hypotensivehypotensive, hypothermic and , hypothermic and unresponsiveunresponsive-- PH 6.7, WBC 8.3, Cr 1.8, PH 6.7, WBC 8.3, Cr 1.8, CTCT followfollow--upup

Our PatientOur Patient FollowFollow--up CCTup CCT

(14)

Our PatientOur Patient Initial vs. FollowInitial vs. Follow--up CCTup CCT

11stst day day 22ndnd dayday

(14)

Our Patient CTOur Patient CT--work upwork up

Loss of gray/white Loss of gray/white differentiationdifferentiationDecrease volume Decrease volume of CSFof CSF--spacesspacesLess prominent Less prominent gyrigyri and and sulcisulci

Cerebral edemaCerebral edema

(14)

Cerebral edemaCerebral edemaDefinitionDefinition: increase in the fluid content of the brain: increase in the fluid content of the brain

A. A. VasogenicVasogenic Cerebral EdemaCerebral Edema (most common form of edema): (most common form of edema): •• 1. Increased permeability of small vessels (breakdown of blood1. Increased permeability of small vessels (breakdown of blood--brain brain

barrier)barrier)

•• 2. Escape of proteins, fluids into extracellular space, especial2. Escape of proteins, fluids into extracellular space, especially of ly of white matter white matter

B. B. CytotoxicCytotoxic Cerebral EdemaCerebral Edema (cellular brain edema): (cellular brain edema): •• 1. Increased permeability of cell membranes1. Increased permeability of cell membranes

•• 2. Excess fluid accumulates 2. Excess fluid accumulates intracellularlyintracellularly; may occur with ischemia or ; may occur with ischemia or with other conditions such as metabolic poisons or water intoxicwith other conditions such as metabolic poisons or water intoxication.ation.

••C. Hydrocephalic (Interstitial) Edema:C. Hydrocephalic (Interstitial) Edema:

•• 1. Fluid flows from CSF into brain through ventricular lining in1. Fluid flows from CSF into brain through ventricular lining in cases of cases of hydrocephalus. hydrocephalus.

All can cause herniationAll can cause herniation

HerniationHerniationSite of herniationSite of herniation Structures involvedStructures involved SignsSigns

Lateral tentorial (uncal)Lateral tentorial (uncal) IIIIII Cerebral peduncleCerebral peduncle Posterior cerebral arteryPosterior cerebral artery

PtosisPtosis, , mydriasismydriasis, lateral , lateral deviation of eyedeviation of eye HemiparesisHemiparesis, , HemianopiaHemianopia

Posterior tentorial (tectal)Posterior tentorial (tectal) Tectal plate (post Tectal plate (post commissure, sup colliculi)commissure, sup colliculi)

Bilateral Bilateral ptosisptosis, failure of , failure of upgazeupgaze

Central tentorialCentral tentorial (axial brainstem)(axial brainstem)

Reticular formationReticular formation CorticospinalCorticospinal tractstracts Midbrain and Midbrain and ponspons

MedullaMedulla

¯̄ consciousnessconsciousness DecerebrateDecerebrate rigidityrigidity ¯̄ or absence of eye or absence of eye movement reflexes, movement reflexes, irregular respirationirregular respiration -- BP, BP, ¯̄ HR, irregular HR, irregular respiration, respiration, apnoeaapnoea

Foramenal (tonsillar)Foramenal (tonsillar) MedullaMedulla ApnoeaApnoea

Subfalcine (cingulateSubfalcine (cingulate Cingulate gyrus, anterior Cingulate gyrus, anterior cerebral arterycerebral artery

Leg weaknessLeg weakness

(9)

Our PatientOur Patient

Patient was transported to BIDMCPatient was transported to BIDMC

BP 90/37, pulse 84, RR 12 and O2 BP 90/37, pulse 84, RR 12 and O2 85%85%

PupillaryPupillary reflex, corneal reflex and reflex, corneal reflex and gag reflexes gag reflexes unreactiveunreactive

Our Patient with Subarachnoid Our Patient with Subarachnoid hemorrhage on CThemorrhage on CT

(BIDMC)

Our Patient: SAH ProgressionOur Patient: SAH Progression

(14), (BIDMC)

Initial film 12h later 14h later

Our Patient with Subarachnoid hemorrhage on CT

(BIDMC)

Subarachnoid hemorrhage

Patient died 2h after arrival at BIDMC-ED

Thanks to:Thanks to:-- Gillian Lieberman, MDGillian Lieberman, MD-- Rich Rich RanaRana, MD, MD-- Andrew Bennett, MDAndrew Bennett, MD

AcknowledgementsAcknowledgements

ReferencesReferencesOestmannOestmann JoergJoerg W.,RadiologieW.,Radiologie VomVom Fall Fall zurzur Diagnose, 2. Diagnose, 2. AuflAufl. . ThiemeThieme

20052005Curtis A. Given Curtis A. Given II,PseudoII,Pseudo--Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: ApotentialApotential Pitfall Pitfall

Associated with Diffuse Cerebral Edema, Am. J. Associated with Diffuse Cerebral Edema, Am. J. NeuroradiolNeuroradiol 24:25424:254-- 256, February 2003256, February 2003

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005.jpg005.jpg9. 9. http://www.aic.cuhk.edu.hk/web8/cerebral_oedema.htmhttp://www.aic.cuhk.edu.hk/web8/cerebral_oedema.htm

References 2References 210. 10. http://geekbaby.files.wordpress.com/2007/06/berry.jpghttp://geekbaby.files.wordpress.com/2007/06/berry.jpg11. 11. www.neurosurgeryroseburg.comwww.neurosurgeryroseburg.com13. 13. http://webeye.ophth.uiowa.edu/ips/IIH/2_iih.jpghttp://webeye.ophth.uiowa.edu/ips/IIH/2_iih.jpg14. Caritas Good Samaritan Hospital, Dept. of Radiology14. Caritas Good Samaritan Hospital, Dept. of Radiology